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Multicenter Analysis of the Factors Associated With Unplanned Extubation in the PICU
Robert K Fitzgerald1, Alan T Davis, Sheila J Hanson
11Pediatric Critical Care, Helen De Vos Children's Hospital, Grand Rapids, MI. 2Grand Rapids Medical Education Partners, Milwaukee, WI. 3Critical Care Section, Medical College of Wisconsin, Pediatrics and Children's Hospital of Wisconsin, Milwaukee, WI.
Insights
Unplanned extubation in pediatric intensive care units (PICUs) is more common in children under 6 years old. Factors like poor sedation and loose endotracheal tubes increase risk.
Area of Science:
- Pediatric Critical Care Medicine
- Patient Safety
- Healthcare Management
Background:
- Unplanned extubation in pediatric intensive care units (PICUs) poses significant risks.
- Identifying contributing factors is crucial for developing targeted prevention strategies.
Purpose of the Study:
- To determine the factors associated with unplanned extubation in pediatric intensive care units.
- To analyze the incidence and risk factors for unplanned extubation in critically ill children.
Main Methods:
- A prospective, case-controlled, multicenter study was conducted across eleven Pediatric Intensive Care Units.
- Data were collected on patients experiencing unplanned extubation and matched controls over one year.
- Multivariate analysis was used to identify independent risk factors for unplanned extubation.
Main Results:
- The overall rate of unplanned extubation was 0.74 per 100 endotracheal tube days, with significant variation between centers.
- Children younger than 6 years had a higher incidence of unplanned extubation (0.83 vs 0.45 per 100 tube days).
- Key factors associated with unplanned extubation included inadequate sedation (OR 9.1), loose or slimy endotracheal tubes (OR 10.4), planned extubation within 12 hours (OR 2.3), and the use of a "floating" nurse (OR 3.8).
- Sixty percent of unplanned extubation events required reintubation.
Conclusions:
- The incidence of unplanned extubation is higher in younger children (< 6 years).
- Patient-related factors (sedation, endotracheal tube security) and staffing issues (use of temporary nurses) are significant contributors to unplanned extubation.
- These findings highlight the need for enhanced monitoring and specific interventions to reduce unplanned extubation events in pediatric intensive care settings.
Objective:
To identify factors associated with unplanned extubation in PICUs.
Design:
A prospective, case-controlled multicenter study.
Setting:
Eleven Pediatric Intensive Care Units collaborating through the National Association of Children's Hospitals and Related Institutions PICU focus group.
Patients:
Patients with unplanned extubation events and control patients without unplanned extubation.
Interventions:
Unplanned extubation events were prospectively tracked for 1 year at 11 centers. When an unplanned extubation occurred, up to four controls were randomly identified of other intubated patients in the unit. For each event and control, data associated with unplanned extubation events, reintubation, and outcomes were collected.
Measurements And Main Results:
One hundred eighty-nine unplanned extubation events occurred out of 25,500 endotracheal tube days in the study (0.74 unplanned extubations/100 endotracheal days; 95% CI, 0.64-0.85), with 654 associated controls. Unplanned extubation rates ranged by site from 0.3 to 2.1 unplanned extubations/100 endotracheal days. Children less than 6 years had an increased rate of unplanned extubation (0.83 for < 6 yr vs 0.45 for ≥ 6 yr; p = 0.001). After multivariate analysis, inadequate patient sedation (odds ratio, 9.1; 95% CI, 4.5-18.5), loose or slimy endotracheal tube (odds ratio, 10.4; 95% CI, 5.0-22.2), a planned extubation in the next 12 hours (odds ratio, 2.3; 95% CI, 1.3-4.1), and a nurse pulled from another unit (odds ratio, 3.8; 95% CI, 1.4-9.9) were associated with unplanned extubation. Sixty percent of unplanned extubations required reintubation.
Conclusions:
The rate of unplanned extubation is higher in patients aged less than 6 years. Patient factors, such as decreased level of sedation, loose or slimy endotracheal tube, and staffing factors such as floating nurse from another unit, contribute to unplanned extubation in children.
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